APA format 3 peer references needs to review case study and document on differential diagnosis as to agreeing or disagreeing  Due October 20.2018 at 5pm

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Episodic/Focused SOAP Note Template

Patient Information:

A.S., 46 F, Caucasain

S.

CC “ankle pain in both ankles; worse in right ankle, after hearing ‘pop’ while playing soccer.”  Episodic/Focused SOAP Note Template Assignment Paper

HPI: A.S. is a 46 year old Caucasian female who presents with bilateral ankle pain which she describes as chronic for the last 3 months. She acutely injured her right ankle 3 days ago while playing soccer. The pain is described as aching with intermittent sharp characteristics. Associated symptoms include limited ROM. The pain is worse with weight bearing and OTC pain medications have included alternating doses of Tylenol and Motrin with moderate relief.

Current Medications:

            Motrin 200 mg by mouth every 4-6 hours as needed for pain

Hydrochlorothiazide 12.5mg by mouth daily for 6 months for HTN  Episodic/Focused SOAP Note Template Assignment Paper

Allergies: PCN- rash, no known food/environmental allergies

PMHx: HTN; immunizations are up to date- last tetanus 12/2017; flu shot 10/2018 cholecystectomy 2015

Soc Hx: A.S. is employed as a Registered Nurse and remains active by playing soccer three times a week. She is married with two teenage daughters. She denies tobacco and alcohol use.

Fam Hx: Maternal grandmother deceased at age 56 from MI. Maternal father deceased at age 75 from complications of COPD. Paternal grandparents unknown. Father history is unknown. Mother is alive with type 2 diabetes that is well controlled with oral agents. Sibling age 43 alive and well. Children are alive and well with no medical hx.  Episodic/Focused SOAP Note Template Assignment Paper

ROS:.

GENERAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema,

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  No burning on urination.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: pain and swelling to right ankle, limited weight bearing and ROM in b/l ankles, worse in the right ankle. No muscle cramping.  No back pain.  Episodic/Focused SOAP Note Template Assignment Paper

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.  Episodic/Focused SOAP Note Template Assignment Paper

GENERAL:  AAOx 3, limping gait, no distress. No fever.  Skin is warm, dry, and intact. Skin of the lower extremities is warm and pink in color.

CARDIOVASCULAR: chest is symmetric with symmetrical expansion, PMI noted at fifth intercostal space at the midclavicular line, normal S1 and S2, no m/r/g, no edema in legs, dorsalis pedis 2/4 bilaterally, normal hair distribution in legs and no pigmentation of b/l legs.

MUSCULOSKELETAL: limited ROM and weight bearing in b/l ankles, worse in right ankle. No clubbing, cyanosis, or edema.

NEUROLOGICAL: mood and affect appropriate, CN II-XII intact. Motor: 5/5 in upper and lower extremities, DTRs 2+ bilaterally.

Diagnostic results:

Ankle x-ray- If the Ottawa ankle rule is positive (bone tenderness at posterior malleolus, bone tenderness at posterior medial malleolus, or inability to bear weigh > 4 steps) ankle radiographs are indicated (Polzer, Kanz,  Prall, Haasters, Ockert, Mutschler, & Grote, 2012).  Episodic/Focused SOAP Note Template Assignment Paper

If ankle radiographs negative- assess ligament in affected extremity as compared to un-injured extremity by doing the crossed leg test, squeeze test, external rotation test, anterior drawer test, and talar tilt test. These tests will assist in determining the need for an MRI and also grading the sprain  (Polzer, Kanz,  Prall, Haasters, Ockert, Mutschler, & Grote, 2012).

Labs may include a uric acid level which is elevated with gout and a WBC which would be elevated with  osteomyelitis. MRI imaging may also be indicted.

A.

Sprain- because the patient heard the “pop” sound, her injury is likely related to an ankle sprain in which the ligaments and tissue that surround the bones of the ankle are injured causing swelling, pain, and limited ROM  (PubMed Health, 2018).  Episodic/Focused SOAP Note Template Assignment Paper

Fracture- a fracture would be unlikely if the patient was able to bear weight after the injury. The area would also become ecchymotic with limited to no ROM (PubMed Health, 2018).

Osteomyelitis- the extremity would be warm, erythematous, not usually associated with an acute injury, potential fever present, usually associated with a systemic infection or a wound (Ball, Dains, Flynn, Solomon, & Stewart, 2015)

Gout- associated with hot, swollen joints, pain and limited ROM (Ball, Dains, Flynn, Solomon, & Stewart, 2015)

Bursitis- limited ROM, swelling, pain, warmth, and point tenderness (Ball, Dains, Flynn, Solomon, & Stewart, 2015)

References  Episodic/Focused SOAP Note Template Assignment Paper

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide  to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Polzer, H., Kanz, K. G., Prall, W. C., Haasters, F., Ockert, B., Mutschler, W., & Grote, S. (2012).

Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthopedic Reviews, 4(1), e5. http://doi.org/10.4081/or.2012.e5

PubMed Health. (2018). Ankle sprains: overview. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072736/

ADDITIONAL INFORMATION;

Discuss acute ankle injuries

Introduction

Ankle sprains are common among athletes and people who spend a lot of time on their feet. They usually cause pain, swelling, and stiffness that can last for several weeks. Ankle sprains are typically caused by an abrupt change in direction or sudden twisting motion. This causes the ligaments at the ankle joint to stretch or tear and results in injury. Acute ankle injuries can be treated at home with rest, ice packs and elevation if possible. If you have chronic ankle pain or osteoarthritis, you may need medical attention from a podiatrist or orthopedic surgeon to determine if surgery is necessary.

What Are the Causes of Acute Ankle Injuries?

A variety of conditions can cause ankle and foot injuries, including:

• Injuries to the joint itself. If you twist, pull or plant your foot on an uneven surface, this may cause damage to the bones in your ankle.

• Injuries to ligaments that support the ankle joint (the anterior talofibular ligament). These are usually treated with rest and ice but sometimes require surgery if they’re severe enough for longer-term recovery.

• Injury to nerves running from front of foot through back of lower leg up into thigh that control movement at these joints (tibial nerve) – this causes weakness in muscles around them causing them not work properly causing pain when walking/running etcetera .

How Are Ankle Pain and Injury Treated?

The most common treatment for ankle pain is rest. This will help your body heal and get back to normal. If you are able to walk on the injured ankle without any pain, then it is okay to do so until the swelling goes down. However, if you have severe pain when walking or twisting your foot, then resting may not be enough.

If you think that rest isn’t enough to reduce your ankle swelling and improve circulation, then try icing the injured area at first before moving on to other treatments such as compression bandages and elevation cuffs (often called traction devices). These devices apply pressure directly onto swollen joints that help reduce swelling and soreness from injuries like sprains or strains caused by sudden twists & turns while running after an injury has occurred!

Is It Possible to Prevent Ankle Pain and Injury?

The best way to avoid ankle pain and injury is by wearing protective gear. If you’re going to do any activity that has the potential of causing an ankle sprain or strain, make sure you wear shoes that will protect your feet from damage. You should also warm up before exercise and take time off from training if an injury occurs. Limiting activity will help reduce swelling in the joint, which reduces friction on the ligaments and tendons that support it. For example, if you’re training for a marathon or other long distance event where walking is required during training, try using elliptical machines rather than running on pavement or grass fields outside so as not put too much stress on your ankles without proper precautions taken beforehand

What’s an Ankle Sprain?

An ankle sprain is an injury to the ligaments that support your ankle.

The ankle is a complex joint, and sprains can be caused by twisting, rolling or landing on an outstretched foot. They can also occur when you land awkwardly from a jump or fall on your feet.

If you have pain in the outer side of your lower leg after jumping jacks or playing soccer with friends, it might be time to visit a sports medicine specialist who can help determine whether this is just soreness from exercise or something more serious such as an ankle sprain

How Do I Treat an Ankle Sprain?

• Rest the ankle. The first step in treating an ankle sprain is rest, which will help to reduce swelling and inflammation. You should avoid any strenuous activities until your ankle has fully healed.

• Ice the injured area as often as needed to reduce pain and swelling; this can also be done using an ice pack or cold compress (such as a towel soaked in ice water). If you have any open wounds on your skin, make sure they are covered with a bandage before icing them so no moisture gets in contact with them.

• Compression therapy: A compression bandage that fits snugly around your leg may help support circulation while it’s healing by reducing swelling and pressure on injured muscles and tendons; however, there isn’t enough evidence yet to recommend its use over other methods like elevating legs higher than heart level or wearing an air cast for short periods of time (usually less than 24 hours).

How Do I Prevent Ankle Sprains?

• Wear supportive shoes. The most important thing you can do to prevent an ankle sprain is to wear supportive shoes. If your feet are not supported, it will increase the risk of a sprain or even breakage of the bone in your ankle.

• Avoid uneven surfaces and stairs with steps that are too steep or narrow for you to comfortably use them with good form when walking or running down them (e.g., if there is no proper handrails). Also avoid stairs where one step may be higher than another due to structural problems such as cracks or missing steps at different heights along its length; these situations could cause people who attempt them unprepared by either falling backwards off their feet onto something hard below them (like concrete), landing on top again but this time without any support behind them whatsoever; or worse yet…

What Is a Broken (Fractured) Ankle?

A broken ankle is a break in the bone of the ankle. The most common cause of a broken ankle is falling from a height, such as when you trip and fall on your foot. It can also happen if you land awkwardly after stepping on something like loose gravel or tree roots.

A cast or brace may be used to immobilize your leg and support it while it heals. For example, if you have a fracture at mid-shaft (mid-tibia), which is near where your knee joint attaches to your thighbone (femur), then you’ll probably need an external fixator—a device that casts over your leg once it’s healed enough to tolerate being moved around again but not yet strong enough for surgery; usually this means about six weeks after initial injury treatment completion

How Do I Treat a Broken Ankle?

If you’re experiencing a broken ankle, the first thing to do is get yourself evaluated by a doctor. Your doctor will evaluate your injury and determine the best course of action.

• Compression: This method involves wrapping bandages around both ankles to keep swelling down while you’re in a cast or boot. It’s important that these bandages be tight enough so that they don’t allow for circulation of blood flow; otherwise, this can cause serious problems down the line when trying to heal from a fracture such as this one!

• Immobilization: This method involves placing an immobilizing brace on either side of your leg followed by securing it with sutures (stitches). This helps prevent further damage from occurring during healing time but does not necessarily mean no movement at all; it just means minimal movement until after healing begins instead which could lead to complications later on down line if left untreated too long without any kind of treatment plan set up beforehand like above mentioned methods above before proceeding further down this road towards recovery.”

How Do I Prevent Broken (Fractured) Ankles?

To prevent ankle injuries, you should:

• Wear good shoes. The right running shoe can help prevent injury by distributing your weight evenly and allowing more cushioning between the ground and your toes. Choose shoes that fit well and don’t slip off or pinch when walking or running.

• Wear ankle braces if necessary (see the next section). Ankle braces are worn around the foot to support it when it is bent, twisted or sprained; they also stabilize weak ankles by providing a solid foundation for them to stand on during recovery exercises like stretching and strengthening exercises for strengthening muscles around injured joints such as ankles/heels/knees etcetera…

Conclusion

Ankle injuries are a common injury in sports, especially for runners. Ankle sprains and fractures can happen when the ankle is twisted or bent from an impact on the ground or from jumping. These injuries can affect your mobility if you don’t treat them correctly, but they’re easily preventable with proper training and good footwear.